Social Determinants and Vulnerability Affect Health Outcomes

Troy Trygstad, PharmD, PhD, MBA

Pharmacy Times, June 2021, Volume 89, Issue 06

Post pandemic, these concepts are hitting the mainstream in the payer, policymaker environment.

Building codes and construction innovations in many coastal communities have improved dramatically over the past few decades. From elevating living quarters above storm surge reach to strengthening structure joints with hurricane ties that withstand the most extreme forces to building with water-resistant materials, beach homes are made to survive severe weather events. Coastal communities and mortgage lenders alike also require and lobby for continued government-backed flood insurance, making it compulsory for most homeowners with residences in areas of risk.

However, not far from the coast are older structures subject to little or no code enforcement. They have scarce resources to carry out updates and are susceptible to Mother Nature’s tantrums, particularly flooding. Off-coast or inland communities in places such as the Carolinas are often economically impoverished, racially segregated, or even devastated by increasingly frequent and intense storms. These primary residences are occupied during all types of weather, with families having no other place to go. Many in these communities are also underinsured or have multigenerational ownership without a mortgage or the requirement to purchase homeowner’s insurance.

Statisticians Armed With Geo Mapping Take Notice

In the 1980s, a mix of new and old satellite capabilities gave us the Global Positioning System (GPS). This eventually enabled scientists to combine mapping and spatial capabilities with other data sets that had been digitized, such as education, income, and education. Now, by using cell-phone positioning, one’s average miles traveled can be monitored for social distancing purposes during a pandemic, for example.

People love maps, and statisticians love data. Public health officials love having the 2 blended to identify risk and risk-reduction opportunities, the ethos of public health. Knowing which areas of the country are most likely to be adversely affected as a result of a natural or unnatural disaster allows for better preparation and resource allocation, especially prior to the event occurring, so that mitigation efforts can be put into place. Responding to this need, scholars began to apply statistical models to predict human suffering and lack of resilience resulting from an event.

CDC Introduces Country to Social Vulnerability Index

The CDC/Agency for Toxic Substances and Disease Registry Social Vulnerability Index (SVI) has become the gold standard for mapping communities at risk. The SVI has 4 core components that determine risk1:

  • Household composition and disability (65 years or older, 17 years or younger, older than age 5 with a disability, or single-parent households)
  • Housing type and transportation (crowding, group quarters, mobile homes, multi-unit structures, no vehicle)
  • Minority language and status (minority and/or does not speak English well)
  • Socioeconomic status (below poverty line, no high school diploma, unemployed)

Pandemic Unmasks Social Vulnerability Nationwide

The CDC has relied heavily on the SVI to aid pharmacy partners receiving COVID-19 vaccine doses so they can identify communities at particular risk. These include low-income individuals, who tend to be essential workforce employees; minority and non-English speaking individuals, who tend to have legitimate rationales for being vaccine hesitant; people living in households with the very old or young individuals, who are more susceptible to disease; those living in multifamily and multigeneration households, who are at greater risk of exposure to infectious disease; and those without transportation, who are less likely to access health care or testing.

Social Determinants of Health Linked to Poor Patient Outcomes

Cousins to SVI, social determinants of health (SDoH) continue to gain recognition and funding and generate action. SDoH concepts use statistical models at the patient level to determine the factors driving health and wellness.

Multiple peer-reviewed and published statistical models corroborate a sobering reality: Just 20% of patient outcomes are due to health care intervention, with genetic predisposition and social determinants making up the balance. SDoH factors such as domestic violence, employment, food insecurity, housing, social stability, and transportation influence health outcomes to a greater extent than clinicians, diagnostic capabilities, and the latest drug to market.

Policymakers, Public, and Health Care System Are Beginning to React

One can reasonably ask why we would spend $3.6 trillion on health care in the United States, more than twice the rest of the industrialized world, when behavioral health providers, nurses, pharmacists, and physicians have little influence on global outcomes. Most citizens would rather have that money for better-tasting food, cars, housing, and smart phones.

Health Care System Starting to Sit Up Straight

Nothing will get an industry to rethink its posture faster than customers and taxpayers rethinking the value of the entire sector. If the public starts to realize that no matter how good a plan, cardiology group, or pharmacy is, they do not really influence health, the industry will start to shift attention and resources to factors that do. Insurance companies, particularly in the Medicaid managed care space, are leading the charge. Not only are they starting to make assessments of SDoH for their members, they are also increasingly partnering with community-based organizations or providing solutions directly to enrollees instead of begging health care providers to change their stances. In other words, address SDoH or become irrelevant versus other agencies, vendors, and government-provided solutions.

Pharmacies Are Well Positioned

Pharmacies are in an advantageous and unique position to respond to the SDoH and SVI movements, but it will require a mindset change. Pharmacist academics often push the notion that it is the comprehensive and unique training in therapeutics that separates pharmacists from other care team members when it comes to providing value. But it is also pharmacists’ placement in communities as accessible frontline sentinels and first responders for disease recognition, management, and triage that allow that training to be meaningful. Yes, pharmacists with clinical capabilities and superior therapeutic knowledge are found in many great institutions of higher learning and advance care delivery, but the data show that those institutions do not play a huge part in the big picture. As a son, parent, or relative of a sick patient, I want those pharmacists there to optimize therapy. But as an individual and taxpayer living in an upper-class neighborhood who feels responsible for investing in the health and well-being of all Americans, I applaud the SDoH and SVI movements on both economic and moral grounds.

These movements represent an enormous opportunity for community pharmacies to reposition themselves. Pharmacies are the front door to the health care system, but they can also be the entrance and major contributors to the infrastructure regarding physical location and personnel, for screening, education, referral, and direct support to address SDoH in highly vulnerable communities and populations.

Critical-Access Pharmacies

Critical-access hospitals serve rural communities that are often at risk for poor outcomes because of their location, geography, social fragility, and, sometimes, poor economic circumstances. With respect to communities with high social vulnerability and prevalent social determinants of poor health outcomes, policymakers should consider a similar model of cost-based reimbursement, grants, regulatory flexibility, and expanded scope of practice. The COVID-19 pandemic highlighted the need for an essential pharmacist workforce in communities of need. Let’s learn from that to ensure those communities have access to local pharmacies.

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